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IntroductionObstructive sleep apnea (OSA) is a major health issue worldwide. In the US alone, approximately 22 million Americans suffer from obstructive sleep apnea OSA and globally it is estimated to affect over one billion adults.1,2 It is estimated that about 22% of men and 17% of women suffer from OSA. The pathology is multifactorial but is characterized by recurrent upper airway obstruction during sleep due to insufficient motor tone in the tongue and/ or airway dilator muscles.2 Factors such as socioeconomic class, diabetes, male sex, tobacco use, alcohol use, increasing age, craniofacial differences, African American ethnicity, and most significantly obesity increase risk.3, 4, 5 Countries with the highest rates of obesity have the highest incidence of OSA and increasing body mass index (BMI) is highly correlated with increasing symptoms in OSA. 6, 7 Patients with OSA will experience any combination of fatigue, excessive daytime sleepiness, snoring, drooling, nocturnal gasping or choking, and headaches. There are many comorbidities also shown to be associated with OSA such as stroke, cardiovascular disease, atrial fibrillation,diabetes, coronary artery disease, hypertension, pulmonary hypertension, and cognitive dysfunction .8, 9, 10 OSA is classified as mild, moderate, and severe; mild OSA is defined as 5-15 episodes of decreased or absent airflow per hour, while moderate is 15-30, and severe OSA being defined as having more than 30 episodes per hour.11 This manifests as hypoxemia, hypercapnia, and intrathoracic pressure changes, increases in sympathetic nerve activity, and fragmented sleep.2, 6 Although continuous positive airway pressure (CPAP) is the first line of treatment for OSA, compliance still poses a challenge with only 40%-60% of patients with OSA tolerating the treatment.3,10,4, 12 Other treatments include lifestyle modifications, dietary modifications, positional therapy(side sleeping), oral appliances, and surgical interventions. 9, 10Hypoglossal nerve stimulation (HGNS) is a safe and effective surgical option used to manage moderate to severe OSA especially in patients who cannot tolerate CPAP.13, 1, 8 The criteria for patients undergoing HGNS therapy include moderate to severe OSA (AHI between 15 and 65), age >22 years, BMI <32 kg/m2, and absence of complete concentric collapse (CCC) at the soft palate level.2 Since the Hypoglossal nerve stimulator device, Inspire, was approved in 2014 by the FDA, more than 18,000 patients have received implantation.11,4 The Inspire device includes a neurostimulator that is placed subcutaneously in the chest with two leads. One lead attaches unilaterally to the patient’s hypoglossal nerve at the base of the tongue and the other lead is placed in the chest to detect breathing. When breathing patterns are detected during sleep, the chest lead relays the information which causes the protrusal branches of the hypoglossal nerve lead to activate, resulting in stimulation of the nerve and therefore contraction of the genioglossus tongue muscles. This contraction results in the tongue moving forward during inspiration, allowing for patency of the airway.14, 5, 15 Although HGNS is mostly used for adults it has proven to be useful in treatment of OSA in pediatric patients with Down Syndrome since they are anatomically at risk for OSA and have difficulty with adherence to CPAP.16, 4 With the increasing use of Inspire and the many comorbidities that accompany patients with OSA, more patients utilizing the device will inevitably undergo other surgical procedures requiring anesthesia. The guidelines for managing hypoglossal nerve stimulation during surgery and anesthesia remains unclear which poses challenges both preoperatively and postoperatively. We present the case of a patient who underwent abdominal surgery with the device off and had postoperative airway complications.